HomeMy WebLinkAbout2025-00042853 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110110011 0 lU VU 00100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003&77615
u, 1 U21 3 4 1 U1 5 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00042853 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED coY 0 N 07 03 2025 ❑AM YES ®No U1 -<
E HIGHLAND AVE Elgin07:21
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W GROVE CT COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRO r TOWED U1 Q
Roa Herrera.Amanda 0 3 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y ❑SNE®UNK VEH. 9 ATCRASHD 9 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a 1i COM VEH 0 j$J 1 n
1- FIRST CONTACT 11 7__ --_;__S *II Yes.See Sidebar U1 0
V Z Schaumburg IL 60194 0 1 0 CN82290 IL 2026 REAR
TELEPHONE
IL D 1 FADP3K2XGL320700 United Security Insurance ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ULS1102358 00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused 0 Y El 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEO ❑PEDAL 0 EWES 0 NOV 0 KCV 0 Dv
yr Q. 12 ,.� -I
o 13-UNDER CARRIAGE i FIRE ❑ ® U2
c
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 1,6.7OP 3
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `OistrasuDn Value 9 U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
POINT OF s i1 5 -
4 COM VEH 0 ® CO
L
FIRST CONTACT 1 Y _, _S •(ryes.See Sidebar
Z WEST DUNDEE IL 60118 0 1 0 FE76557 IL 2026REAR
C
IL D 3N8AP6DD5SL377787 Geico ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
KACHI ENERGY INC 6200228512 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 07,03 ,2025 07 21 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 06 20 , ) 0 PM ❑Construction *
7
Z 3 0 Ig CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Roa Herrera,Amanda 11-801 1560000026 / ! 0 PM SLMT
S' N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME0 Am• ❑Utility
r 2 0 29 2 ARREST NAME 07/03 r2025 08 24 ®PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1560-Jones, Bennett 101 08 ,05,2025 09 00 ❑PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
Hghlmrd7Ave. ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds{example:truck or truckrtrailer -<
i- ---_--I-----; z } combrtatbn)or
t� INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
II
31
_ } (example:shuttle or charter bus):or
A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
Grove�at } } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w
73
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct com nation exam I lar a van used for specificpurpose):or [he driver,
- - - - - - Pe ( P 9 Pe or o
L L____a____. L 5 Is an vehicle used to transport any hazardous material(HAZMAT)that requires -U
m
' ,.#,t placarding(example:placards will be displayed on the vehicle). XI
Not To Scale l CARRIER NAME Z
' 1......... ADDRESS 0
CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate 5
1 HLI
f ❑ NotinComm./G . NotinComm. er
1I ❑ C USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
0 Yes II El Unknown C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No -
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gold Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE